Category Archives: Septoplasty

Deviated Septum for Josh Hutcherson

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"Movie star Josh Hutcherson leaves a doctor's office after nasal surgery"

Josh Hutcherson after deviated septum surgery

On May 16th the blogosphere was all atwitter about the nasal surgery on Josh Hutcherson, a star of the smash movie, “The Hunger Games.”

At first, bloggers rose up in arms, decrying Josh’s “cosmetic surgery” on an already perfect nose with some exclaiming, “Say it ain’t so, Josh!”

Later, Josh appeared in the streets leaving the office of a Beverly Hills plastic surgeon, tweeting still later that he had surgery on a deviated septum.

Quickly jumping into the fray were badly informed bloggers who jumped to conclusions like:

  • Josh had been injured in a bar fight
  • Fans had mobbed him

(Blog post continues below.)

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The young soccer player just below shows on the left his bent nose (which also had a bent septum) after two failed nose jobs done elsewhere. His restored shape and septum allowed for normal breathing. (Robert Kotler, M.D. photos.)

"A young man shows his new nose after rhinoplasty on a bent nose"

 

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(Continued from above.) But Josh set things straight when he tweeted what was actually afoot.

But what is that, a deviated septum and why was he having surgery on it?

The septum is a thin wall of cartilage and bone dividing the two nostrils. If it is bent, twisted or is otherwise knocked out of a straight up-and-down position, it’s medically known as a deviated septum.

You can be born with a bent septum or suffer a blow to the nose. An uncorrected broken nose can leave a septum in an “S” shape that really messes up breathing.

Why? A bent septum can block the breathing channels that pass air to the lungs. It’s very noticeable at night when the sufferer snores and perhaps wakes up gasping for breath.

Medically speaking, it’s not a good thing. A deviated septum and the snoring don’t allow enough oxygen for healthy functioning of the body’s organs.

Plastic surgeons who specialize in head and neck surgery are often masters of all things nasal and can quickly detect deviated septums as well as straighten them.

Depending on how much the septum is bent, some cases can be repaired using stiches only inside the nose. Other deviations require tiny amounts of the septum to be surgically removed, with the two ends sutured together.

Some have the surgery under local anesthesia while others are put gently to sleep under general anesthesia.

Josh appears in the photo above wearing what some call a “moustache bandage” to absorb any nasal bleeding.

Most patients go home the same day, many with packing inside the nose to hold everything in place and to deliver healing medications. Most complain about packing and nasal stuffiness, but if the nasal surgeon has used a Kotler Nasal Airway, recovery is more pleasant.

(Read more about the Kotler Nasal Airway.)

Dr. Kotler: Ranked by MapQuest as #5 out of 500 medical & health professionals in Beverly Hills’ “Golden Triangle”

 

Deviated Septums: How Cosmetic Surgeons Treat Them

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"A lovely woman holds her nose because she can't breathe"

My nose constantly drips!

Scan the many bulletin boards where people ask questions about their suffering from nasal blockages and you’ll see many mentioning surgical treatment for a deviated septum.

For instance, Bob23, Junebug and wannasnooze on the American Sleep Apnea Association’s Support Forum all mention deviated septum surgery as their treatment for:

  • Problem snoring
  • Sleep apnea
  • Infected sinuses
  • CPAP (continuous, positive air pressure) replacement
  • Constantly stuffy or constantly dripping nose

First item for anybody headed for septoplasty, the surgery to correct a deviated septum: a thorough exam by an Ear, Nose & Throat (ENT) physician or surgeon. Why? There may be other reasons for the symptoms.

Once everything else is eliminated, surgery is the only way to straighten a bent septum while restoring healthy, quiet breathing and the normal flow of nasal mucus.

Often performed by a cosmetic plastic surgeon with many years’ surgical experience on noses, the septoplasty procedure reshapes nasal bone and cartilage inside the nose without changing the appearance of the nose on the outside. However, if you don’t like your nose, during the same surgery would be a good time for rhinoplasty. (Yes, a nose job!)  The two procedures can be done in a single surgical session. Septoplasty itself has been done since 1902. (Blog post continues, below.)

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In the top photo below, the patient’s left nostril is blocked by a deviated septum. The bottom picture shows correction of the deviated septum (septoplasty) which no longer blocks the breathing channel. Moreover, the man had rhinoplasty during the surgery. (Photo, Robert Kotler, M.D.)

"A patient shows his repaired deviated septum in before and after pictures

Deviated septum surgery and rhinoplasty

 

 

 

 

 

 

 

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(Continued from above.)Depending on the particulars of a case, other internal nasal structures known as the turbinates may also become involved. Turbinates are bony, flesh-covered structures in the upper nose and can block healthy breathing due to swelling caused by any number of reasons.

Actually, having deviated septum is incredibly common and ranks as the third most frequently performed operation of the head and neck. Some are born with a bent septum while others knock the septum from its normal position in:

  • Car accidents
  • Sports
  • Fist fights

Another septum problem, cocaine abuse, can lead to hole in that structure, creating a whistling with each breath. (Read more about the septum and cocaine abuse.)

After septoplasty, most patients notice some swelling and discomfort which is easily controlled with medications.

Yet another critical step is thoroughly checking the credentials of the nasal surgeon you use. Check for board certification in a specialty known as Otolargyngology and, for cream of the crop, a head and neck surgery fellowship.

Also, look for a surgeon who uses the Kotler Nasal Airway, a device that helps you breathe while nasal packing is inside the nose, after surgery. (Watch a video about the Kotler Nasal Airway.)

Dr. Kotler: Ranked by MapQuest as #5 out of 500 medical & health professionals in Beverly Hills’ “Golden Triangle”

Deviated Nose: Down in the Dumps?

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"A sad or depression man is shown with his head in his hands"

Deviated Septum?

Scientists are always studying things. There was once a serious study to find why toast always falls to the floor, buttered side down. (We are NOT making this up!)

We were actually looking for a study about deviated septums leading to depression but, but came across the buttered-toast-falling-to-the-floor study.

Ever since, scientists have worked on various other factors affecting the downward flight of buttered toast toward your kitchen floor. Query the phrase, “Why toast falls to the floor buttered side up” you’ll find at least 18 journal articles on Google Scholar.

Oh well, back to septums. We also observe that nose job patients coming into our office asking about rhinoplasty  often complain about a nose that does not breathe well. And they also tend to not feel so well. You can pretty much take it for granted.

But has it been officially studied by cosmetic plastic surgeons or anybody else? Not until now.

Eight Brazilian Ph.Ds noticed the same thing – that bends, twists and swollen structures inside the nose can affect your life in more ways that just poor breathing.

So they studied the effects of:

  • A deviated septum
  • Other internal nasal blockages

Sixty patients were rounded up with 32 assigned to a deviation group. Another 28 who had no nasal blocks were put in a comparison group.

Then, all sixty filled out several questionnaires on general health. Findings included that the deviation group had 11 depressed people while the non-deviation group had only two.

Moreover, the deviation group had a “worse quality of life score” while the non-deviation group enjoyed a 90 percent rate of physical functioning (running, sports, doing housework, etc.) But the subjects with breathing obstructions only had a 77 percent rate of ability doing physical tasks.

Overall, a deviated septum was linked to feeling tired, worn out and having less energy. The blocked nasal group also had more emotional problems and did not get along with others as well as those in the no-deviation group.  (Read the deviated septum and depression article.)

For women, that meant having a blocked nose can cause more:

  • Introversion
  • Immaturity
  • Obsession with self-image

It gets worse for guys with blocked noses; they tend to be stubborn, skeptical, pessimistic and perfectionist.

Commonly reported among both men and women with nasal deviations:  they “feel so down in the dumps that nothing could cheer them up.”

Unfortunately, “nasal deviation” covers a lot of ground. Anybody with a deviated septum or blocked turbinates could fit into the group.

"One man is shown in before and after pictures with a deviated septum repaired:

Before and After Deviated Septum Surgery

Sinus Woe? Inside Help Needed!

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"A lovely woman blows her nose due to Spring allergies on her sinus"

Sinus Woe Begone!

Ever spot a slick sinus cure on TV and think you could use some over-the-counter relief? Hey, join the crowd!

According to Google.com, over 3.3 million computer users monthly type the word “sinus” into a search box, looking for help with nagging sinus blues, supposedly centered somewhere up in your schnozzle.

Another 3/4 million search for clues about “sinusitis” while an additional half million look for hints on what to do about “sinus infection.”

Count the incredible number of “cures” on the shelves at your pharmacy; all are devoted to improving blocked noses and sinus function. At one, we counted 66.

TV advertisers are hip to the many complaints, offering as “sinus relief” dozens of  remedies, including:

  • Pills
  • Nose drops
  • Nose sprays
  • Stick-on tape to open nostrils wider

But real sinusitis won’t be touched by any of the above. If your sinus passages are infected, you’ll have very serious symptoms, including:

  • High fever
  • Nausea and possibly vomiting
  • Facial swelling
  • Pain

The list of complaints really goes downhill from there, with various types of goo pouring from the nose into the throat. In true sinus cases, strong pain meds are a must.

Here’s what’s usually happening: inside your nose are various nasal parts that help breathing; some just pass air on to the lungs while others help warm it and even filter out germs and dust.

When those passages become blocked, twisted, bent or otherwise seriously tweaked, you develop bothersome symptoms that only look like true sinusitis. Even allergies can kick up problems.

Many patients first discover that some inside-the-nose help is needed when they go to plastic surgeons asking about rhinoplasty. In many cases, a deviated septum, the internal thin wall that separates the nostrils, is the bugbear.

Other symptoms that your nose needs inside help include:

  • Snoring
  • Healed broken noses
  • Postnasal drip
  • Nasal congestion
  • Twisted noses

After a cosmetic nasal surgeon takes a peek inside a nose, he or she can do a type of procedure – a nasal septoplasty — that changes your internal nasal passages from the equivalent of a twisted, one-lane country road to a six-lane freeway with no speed limit on air rushing through your nose to the lungs.

Also commonly done: reduction of the inferior turbinate, a shelf of bone covered with a lining of thick skin further up in nose.  That reduction further contributes to opening the airway and reducing the chance of additional sinus problems.

Smokers have the breathing thing even worse, given the constant bath of hot, dry and irritating (to both internal nasal structures and your companions) cigarette smoke.

A purely cosmetic rhinoplasty won’t help — you need an “inside job”. Facial plastic surgeons, who typically are super-specialists with core training in head and neck surgery (including ear, nose and throat) are the experts.

Those surgeons will know what to do.

Sleep Apnea on the Rise

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Recently, the Health & Wellness section of the Los Angeles Times had two excellent articles that dealt with the problem of sleep apnea and snoring

According to the Los Angeles Times, “2% of women, or at least 4% of men, suffer from obstructive sleep apnea.”  If you are not familiar with sleep apnea, it is a condition “in which the airway collapses and blocks breathing for 30 seconds, or even up to a minute or two.  The brain senses that it isn’t receiving enough oxygen and sends a signal to the patient to wake.”

People with sleep apnea (apnea is translated as “without breath”), find themselves in an unsatisfactory and untenable situation because their sleep quality is poor.  Poor sleep quality can generate  a myriad of problems including sleepiness at work and leisure, and even possible elevations of blood pressure, and other imperfections in your normal bodily function.

Maybe there is a connection between the rise in obesity in the United States and sleep apnea.  The paper says, “the incident rises with age: experts estimate that it affects about 40% of people age 65 and older.”  What we are seeing in the United States is that older people tend to be heavier.  That is not good news on many fronts. 

The articles also points out that it’s not just about age.  The overweight issue is very significant.  Overweight patients have double the risk of sleep apnea according to Dr. Lawrence Epstein, of a sleep center chain in Massachusetts.  Incidentally, if you have ever seen kids with large tonsils and adenoids struggling to get breath when they are sleeping at night, which is not that uncommon, you have a clue as to what sleep apnea is like. 

The article pointed out that there are mechanical remedies available including the infamous CPAP (“Continuous Positive Airway Pressure”) device, which is a spaceman-like mask which affixes tightly and to the face, akin to a scuba mask.  An external electrical power source drives the air into the lungs under pressure at night.  It is not too pretty; but, it does provide relief for people. 

Other technical aids are dental mouth pieces, and even some of these external nasal breathing strips. 

I was a bit disappointed that the article did not discuss management of one of the key causes of sleep apnea – that is a blocked nose. Nasal obstruction.

More on that to follow because there is a huge pool of patients in the United States, and worldwide, whose problems can be helped with a veteran, venerable, and reliable one-hour surgical procedure – nasal septoplasty and turbinate resection, with or without rhinoplasty. 

~Robert Kotler, MD, FACS

 

 

ALLERGY DRUG, NOW FDA APPROVED, PROMISES BETTER BREATHING

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Several months ago, the United States Food and Drug administration gave approval to sell Allegra, an anti-allergy pill, without a prescription.  The entire Allegra family of products will be available on drug store shelves.

The product has been on the market for quite a few years and there are other products that purport to provide the same benefit.  The rationale for taking these medications is that through certain biological pathways, the medication will blunt the effect of those substances to which the body is allergic.  It is the allergic reaction which causes the symptoms of blocked breathing, runny nose, itching, sneezing, watery eyes, etc.  It’s no fun.  I can tell you from my own experience that as a child and adolescent, I had quite bad allergies particularly to ragweed which is endemic during the late summer in the upper midwest. 

According to the Asthma and Allergy Foundation of America, there are approximately 40 million Americans who have both indoor and outdoor allergies.  According to the article, the most common triggers are tree, grass and weed pollen; mold spores; dust mite and cockroach allergen and cat, dog and rodent dander. 

One issue that always comes up is how effective are these medications in terms of relieving the blocked breathing.  It has been my observation while they can be helpful when alleviating the other symptoms which besides those mentioned above can include even a scratchy throat and a red and unique sensation of itchiness in the throat.   But, I find such pills, tablets, syrups or whatever woefully inadequate in providing a normal airway for patients.

I realize I’m taking issue with a huge economic force, a large commercial market selling billions of dollars worth of medications – prescription and nonprescription  – to the public with the promise of helping breathing.   In my opinion, there is no substitute for the one-time, one-hour surgical procedure that for nearly every patient will bring lifetime relief.  The classic and typical procedure is correction of a deviated septum, if that is a factor and it often is, and thereby restricting the airflow regardless of the status of the lining of the nose which is the target for the allergic reaction, and most importantly, trimming by various means including surgical excision, laser, and other technologies, enlarged turbinates.  The most commonly enlarged turbinates are the right and left inferior turbinates.  While there are a total of six, three on each side (upper, middle and lower turbinates), it is the lowers that have the greatest potential for severe swelling as the lining is attacked by the allergen.  Incidentally, the same process takes place when you get a cold.  In that case, the virus invades the tissue inciting a reaction by the body causing the lining to swell.  When the lining swells, the diameter of the air passage in the nose diminishes.

I am an advocate of the surgery because patients appreciate that it is a one-time cure.  As one doctor-patient unfairly credited me with a big victory:  “Dr. Kotler, you cured my allergies.”  I really didn’t cure the allergies.  But what my surgery did was create such a large internal nasal airway that even when he had an allergic attack, and the lining swelled and thus diminish the airflow, there was so much extra room that he could still have satisfactory breathing. 

I liken it to converting a two-lane highway to a four-lane highway.   Even if there is a minor accident – the analogy here is that the accident is either an allergy attack or cold – there is still room for the airflow or traffic to pass.

Recently, I made my contribution to improving that operation by developing what is now known as the Kotler Nasal Airway.  This is a right and left medical grade silicone soft tube that the surgeon seats on the floor of the nose after the corrective nasal surgery that allows the patient to breathe despite the rest of the nose being swollen and/or being packed with various cotton-like substances that surgeons use to help keep the tissues in proper position and reduce bleeding. 

The patient satisfaction rate for the operation itself has been high but the postoperative period, heretofore, before use of the Kotler Nasal Airway, has been less than popular because of the misery of what one patient described as “feeling like I had a clothespin on the tip of my nose for five days.”

Science never sleeps.  We move forward and any contribution that makes an operation more palatable, comfortable and successful is always welcomed.

~ Robert Kotler, MD, FACS

 

Rhinoplasty Packing Anxiety

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After nasal surgery, cosmetic or reconstructive to improve nasal breathing, there is generally some sort of “packing” placed inside the nose.  The same process for people having a nasal and sinus surgery.  Whether it be a cotton pad or Telfa, or cloth-like material, the purpose is to maintain the reconstructed parts in the proper anatomic position, reduce the chance of bleeding, and to deliver important medications into the tissues, such as antibiotics and even medications to speed healing.  So, packing has always been a traditional part of rhinoplasty, nasal septoplasty, and turbinate resection, but not necessarily welcomed by patients. 

Patients, understandably, dislike the complete blockage, the feeling as though “there is a clothes pin put on my nose.”  They do not like it because it produces a dry mouth and, worse, a sense of anxiety that they cannot catch their breath.  One patient likened his experience to being “waterboarded.”  Another said it was one of the worst experiences of his life because he was very anxious, he could not sleep, and was “generally miserable.”

Interestingly, the specialties of facial plastic surgery, head and neck surgery, ear, nose and throat and general plastic surgery have not paid enough attention to  patient satisfaction with the post-operative experience. While the results of the rhinoplasty and other procedures generally been good, patients rarely give high grades to the experience.

With that in mind, recently, I have developed a new medical device that allows patients to breathe completely freely and normally during the entire postoperative period, including right after surgery.  This Kotler Nasal Airway is placed by the surgeon at the operation, and then the packing is placed.  So, the airway is guaranteed, and the comfort and security of being able to breathe is assured. 

More to follow on this later.

Rhinoplasty Cost

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Beverly Hills Rhinoplasty Cost

Patients always wonder whether or not there is a “excise tax” placed upon surgical fees in Beverly Hills.  In other words, are people paying for the location, perhaps, without any correlation with quality.

The hard economic reality is that the costs of doing business are higher in Beverly Hills.  Particularly, the so-called “Golden Triangle,” where there is an extremely high concentration of some of the most sophisticated specialists – in all areas of Medicine – residing.  It is a medical campus without a hospital.  But, there are many outpatient surgery centers for the types of elective surgery that we perform, for example.  So, yes, the cost of doing business is higher in Beverly Hills, and, therefore, the surgeon’s fees may be a bit higher.  But, they are not double or triple what they are elsewhere. 

There are advantages to seeing doctors who are at the top of the list of super specialists because they tend to be the most proficient in the procedures they perform, and they tend to congregate together.  The reasons why the highest quality physicians and cosmetic plastic surgeons tend to congregate is that there is ease of consultation and referral.  These translate into significant benefits for patients.  Some of our patients come from out of town and appreciate the fact that we can make arrangements with the other specialists whom they may want to see for other services.  For example, patients often come to see us to have rhinoplasty, cosmetic nasal surgery, and also septoplasty and turbinate resection for breathing.  They may also want to have breast augmentation.  We have a very close working relationship with some of our plastic surgery colleagues who specialize in body plastic surgery, and; therefore, are super specialists “below the neck,” as we are super specialists “above the neck.” 

Typically, fees for cosmetic procedures do not have that wide a variation.  Therefore, while it may cost perhaps 10% or 20% more to have the procedure done in Beverly Hills, most patients feel that, indeed, “you get what you pay for,” and if the most highly skilled, most super specialized doctors are in Beverly Hills, because they are there in a central location surrounded by other top specialists then, it is not unreasonable to pay a bit more. 

 

Rhinoplasty Surgery in Hollywood

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Rhinoplasty Surgery in Hollywood

Rhinoplasty, which is cosmetic plastic surgery of the nose, has long been staple in Hollywood.
The reason is that Hollywood thrives on showing the world beautiful faces and it is impossible to have a truly beautiful face without a satisfactorily-shaped nose.

Some people are lucky and are born with a nose that is proportional and is pleasing to the eye.  Elizabeth Taylor comes to mind.  Likewise Grace Kelly and Catherine Deneuve. 

Those who have not had luck on their side with respect to receiving a “good nose”, have always had the option of having the rhinoplasty surgery. Of all the procedures that a younger person can do to improve their appearance, rhinoplasty ranks number one.  It is more important and more commonly requested than chin augmentation or blepharoplasty.

Remember, also, that many people have the rhinoplasty surgery at the same time as they have nasal septoplasty and turbinate resection to improve the airway or correct a sinus problem. This “double need” is more common in men than women, of course.

Marilyn Monroe had rhinoplasty.  Comedian Milton Berle and actor Dean Martin also had rhinoplasty.  

Years ago when I was researching for my book, Secrets of a Beverly Hills Cosmetic Surgeon, I visisted a photo archives facility in Venice, California.  It was fascinating to leaf through the drawers and recognize that many familiar faces had indeed had rhinoplasty surgery at some point in their life. 

Incidentally, some people go to great lengths to conceal the fact that they are having such surgery.  If you ever saw Barbara Streisand in the movie Funny Girl, you would know that it was the story of comedienne Fanny Brice.   In the 1930s, Fanny had a rhinoplasty performed in a hotel suite.  She felt that was the best way of keeping it a secret.

Today, rhinoplasties are not performed in hotel suites and, frankly, they are rarely performed in hospitals.  It is appropriate to perform such a procedure in a credentialed outpatient surgery center or a duly qualified physician’s office surgical suite. 

Rhinoplasty For Men

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Men’s Nose Jobs

I have been thinking a lot about men’s rhinoplasty or cosmetic plastic surgery of the nose, the last several days.  In the last two days we performed nasal cosmetic and reconstructive surgery on two gentlemen.

The first was a middle-aged businessman who had difficulty breathing, but who also was motivated by the fact that he felt his “nose was growing”.   The nose, in fact, doesn’t grow, but the tissues within the nose, the loosen, the tip drops and the nose appears more bulbous and longer.  The gentleman’s motivation for that cosmetic enhancement was proper.  Likewise, the desire to breathe was very reasonable and the patient’s deviated septum and enlarged turbinates were causing blockage such that snoring and poor sleep quality was the result.  So it all made sense. 

In the case of that middle-aged gentleman it was very important to fully understand the man’s wishes.  He expressed on several consultation visits the need to have a natural looking nose that would not look artificial, “done” or drastically different from that which his face had carried for many years.  A surgeon needs to listen carefully to these words and understand the mission.  Any miscommunication could result in an unsatisfactory result and an unhappy patient.  That is not what a conscientious and competent cosmetic facial surgeon wants.

The second nasal case involved a young man who had had two prior nasal surgeries, one for breathing and one for appearance.  The former, the nasal septoplasty, was accompanied by reduction of the turbinates.  The turbinate reduction was quite satisfactory but the septum was still deviated to one side, meaning he had internal nasal blockage because of the shift of the septum which is the vertical partition that separates the two nasal passages.  Those “ revision septoplasty operations are not easy because typically some of the cartilage has been taken out of the septum and there is quite a bit of scar tissue underneath the internal lining of the nose.  It does call for considerable experience, expertise and judgment.

The young man’s other wish was to have his nose appear less long.  Indeed the nose was too long for his face and, as he ages, the length would have only increased.  Apparently the original operating surgeon did not heed the patient’s advice and the result did not match the patient’s wishes.

At this young man’s surgery, very conservative elevation of the nose was done such that it no longer looked too long as if it would touch his lip when he smiled.  And indeed, regarding smile, part of the problem was that he had a very strong muscle which, upon smiling, would depress the tip of the nose further.  The breathing problem was corrected by straightening the septum and some other relatively routine internal procedures, and we were able to lift the nose off the lip, release the muscle which had been exerting its downward force on the lip and give him a natural looking nose which was not radically different from what he had before. But certainly better and in keeping with his desires.

It is very important for surgeons to listen to patients, to get a good sense of what they want.  Also, in my opinion, it’s important have computer imaging available so that the perspective patients can see the predicted results of the procedure that the surgeon deems achievable and reasonable.  A meeting of the minds should take place at the computer imaging session such that the patient and the doctor are on the same page based on that computer visualization of the end result of the cosmetic rhinoplasty.

We have used computer imaging in our practice since 1989. It is helpful and important to patients who need the comfort of seeing the projected outcome.